EFTA00027224.pdf

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pdf

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data-set-8

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Washington, D.C. 20530 
US. Department of Justice 
Request for Financial Information Under the Right to Financial Privacy Act (RFPA) 
(Authorization, Purchase Order and Receiving Report) 
This form shall be used when requesting financial records of individuals and partnerships of five or fewer individuals under die RFPA. 
I Tracking Number 
j2 Date Order Prepared: 
4 Name and Address of Financial Institution: 
5 Deliver Records To: 
Section A - Authorization and Purchase Order 
Funding Certification & 
Authorization: 
3 USAO Number: 
A. 
Budget Official Signature 
Funding Available 
Date 
B. 
54-8113 
N/A 
 
 Apprining Official Signature 
Date 
Send Completed USA-21 I Form & Invoice To: 
6 Return Date: 
V.S. Attorney's Office • SDNY 
Budget 1 Fiscal Unit 
86 Clambers Street. led Floor New York. NY 10007 
7 Remarks: Do not proceed with compliance if the total cost will exceed $ 500.00 
without prior approval. To obtain approval. call the requestor listed in Item 8. 
If invoicing for these services is expected to exceed 120 days. please notify the United States Attorneys Office immediately to ensure funds remain available 
for payment. Please see the attached Important Notice for additional information on invoicing and other requirements for reimbursement. 
8 Name of  attestor 
AUSA 
Telephone Number 
Section B - Financial Institution Invoice 
10 Date of request: 
No Payment Shall Bc Made Unless Expenses Arc Itemized Below Or Set Forth On Your Attached Invoice. 
IIA Invoice Number
11B Tax ID Number: 
I IC Service(s)/Records Provided: 
A. Searching and processing costs (clerical or technical personnel) 
B. Searching and processing costs (management/supervisory personnel) 
C. Searching and processing costs (computer support specialist) 
D. Reproduction Costs (Photocopying) - **Note: Copy charges will be disallowed if 
the information is stored electronically. unless the US Attorney's Office requests paper. 
E. Reproduction Costs (Paper Copies of Microfiche: provide just…

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